Clinicians Spreading Germs In hospitals, patients are supposed to get better, not worse. And doctors are considered healers, not agents of harm. But evidence shows that insufficient hand-washing by clinicians spreads germs. Infection-control experts are exploring how, other than hand transmission, physicians and healthcare workers are spreading germs. As a result, virtually everything a doctor takes from room to room—including stethoscopes, cell phones and mobile devices, ID badges on lanyards, clothing, and lab coats—has come under scrutiny as a potential vehicle for microbugs seeking a lift. To date, though, the research hasn't produced the smoking gun that evidence-minded physicians demand. That's left the medical community divided between those endorsing the better-safe-than-sorry approach, based on the "biologic plausibility" that clothing and other items can be vectors for infection, and those who say unproven theories should not shape healthcare practices. Where is the line between practical patient protection and overblown fears? It depends who you ask. Physicians are divided. Biologic Plausibility vs the Appearance of Professionalism The maintenance of hygienic conditions is important for physicians in all settings. However, the debate over physician attire is largely taking place in hospitals—not outpatient clinics or offices—because hospital patients are more vulnerable, the intensity of exposure is greater, and the organisms in question are more dangerous. Each year, an estimated 722,000 healthcare-associated infections occur in US hospitals, resulting in about 75,000 patient deaths, according to the Centers for Disease Control and Prevention.[1] It is a challenge to identify the potential culprits behind these infections. Although numerous small studies have found pathogens crawling on hospital workers' apparel, including ties, scrubs, and doctors' white coats, none have established that those germs have resulted in patient infection. "We don't have evidence that if we took the white coat away, infection rates would go down," says Michael Edmond, MD, chief quality officer and clinical professor of infectious disease at the University of Iowa Hospitals and Clinics in Iowa City. What's more, it would be extremely difficult and costly to gather that evidence. For that reason, not everyone is waiting for proof. In January 2008, the National Health Service adopted a "bare below the elbows" (BBE) policy throughout the United Kingdom, which calls for short-sleeved lab coats, no wristwatches, no jewelry, and no neckties. BBE gained attention in the United States in 2014, when the Society for Healthcare Epidemiology of America (SHEA) issued attire guidelines for healthcare workers in non–operating room settings. [2]Although the guidelines favor a BBE policy, they note that when facilities and physicians choose to retain long-sleeved white coats, steps should be taken to reduce the potential for germ transmission. For example, facilities should provide coat hooks so that doctors can remove their coats prior to contact with patients, and physicians should own at least two coats and make sure that they are laundered at least once a week and when visibly soiled. As for neckties, SHEA experts say the jury is still out but recommend that doctors who wear them secure them with a clip or coat so that they don't come into direct contact with a patient. Gonzalo Bearman, MD, lead author of the guidelines and chair of the division of infectious diseases at Virginia Commonwealth University in Richmond, is the first to admit that there is no proof that BBE, or losing the white coat altogether, reduces infection rates. That's why the recommendations are sprinkled with words and phrases like "paucity of data," "biologic plausibility," and "guidance." Although Dr Bearman says that the recommendations constitute a voluntary, low-cost, low-effort, low-risk, "common-sense approach" to reducing potential infection risks, that hasn't made them an easy sell to the medical community. In a straw poll held after a debate on the issue at ID Week 2015 in San Diego, 42% of audience members favored a BBE policy and 58% opposed it. Are Bare Arms More Hygienic Than Sleeves? Physicians' objections to BBE are far ranging. Some note that there is no indication that bare forearms are any more hygienic than sleeves. Others point to research showing that some patients prefer the professionalism signified by a white coat. (Still other studies show that patients prefer physicians to be BBE after the rationale for the attire is explained.) But patient perceptions are only part of the story. Although three-quarters of physicians and medical students surveyed by Dr Bearman and his colleagues felt that white coats were "probable or definite vectors for pathogen transmission," and two-thirds said that BBE was "probably or definitely effective at reducing transmission of hospital pathogens," many doctors are loath to lose the coat. Medscape article on white coats. Another noted that "wearing a white coat is a sign of respect for patients, the profession, and ourselves." And one physician explained that a function of the white coat "is to distinguish status (for lack of a better term). As a young woman, I'm often mistaken for a nurse or other paramedical professional." "The most interesting part of all this is the sociological and psychological aspects of the white coat," says Dr Edmond. "They feel they have to have it as a means of identification. What do you say to that?" Rather than getting bogged down in the white-coat debate, Angela Vassallo, MPH, MS, director of infection prevention and epidemiology at Providence Saint John's Health Center in Santa Monica, California, and a member of the Association for Professionals in Infection Control and Epidemiology, says she'd like to see doctors who feel strongly about their coats simply adopt the precautionary measure of laundering them at least weekly. "It's just common sense." That way, the medical community can focus on more frightening potential threats, such as stethoscopes and cell phones, she explains. A Swiss study of the contamination of stethoscopes and four different areas on physicians' hands after a physical exam revealed that the diaphragm of the stethoscope and the tube are the second and third most contaminated surfaces, behind physicians' fingertips.[4] Vassallo says she wants to see more research on the topic, and clear recommendations. Although disinfecting a stethoscope with alcohol-based disinfectants between uses has been shown to reduce bacterial contamination, the optimum method for cleaning stethoscopes has not yet been defined.[5] "I'd love to see everybody get doused and changed when they came into the hospital," she jokes. "That's an infection preventionist's dream, but I don't think it's going to happen. We need to focus on good cleaning and disinfection of stethoscopes and cell phones between each use. Every time you touch it, there's a chance to spread germs." Hand Hygiene Is Key For all the debate surrounding the role clothes and devices play in the spread of infection, it is important to note that hand hygiene is the way to protect patients. Research suggests that anywhere from 20% to 40% of hospital-acquired infections come from the hands of healthcare workers, notes Dr Bearman. Despite its central role in reducing infection risk, hand hygiene is still not practiced as routinely as it ought to be. The Centers for Disease Control and Prevention, which launched its Clean Hands Count campaign in May, estimates that some healthcare providers practice hand hygiene less than half as often as they should.[6] What's more, research conducted at the Santa Clara Valley Medical Center in San Jose, California, suggests that hand-cleaning compliance rates might be lower than generally reported because doctors and nurses are more likely to clean their hands if they know they are being monitored. The study showed a difference in hand-hygiene compliance of more than 30% between doctors and nurses who knew they were being watched and those who did not.[7] When it comes to hand hygiene, "there's always room for improvement," says Dr Bearman. "Frequent reassessment and re-engagement" is needed, he adds. "Things such as apparel and wiping down stethoscopes should never detract from the cornerstone of infection prevention, which is hand hygiene." Source
